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07/29/2015 1 : 21 : 11 PM -040- FAXCOM ANYWHERE , E 4 OF 4 <br /> GEWED i L EHD LOG NUMBER <br /> v SAN .JOAQUIN COUNTY 1. <br /> JUL 2q 2015 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> RALHNphone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/eh <br /> PERMIT[SE1311M PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: (� rya. �ill� . BUSINESSIAGENCY: P/1 <br /> �hU;r�,�r�e,�' dt .�►1c <br /> ADDRESS: �j`�c �aS �iY t �J �� CITY/STATE/ZIP: a�,;���� 6A <br /> PHONE (1): c7Z6 7q5 41121-) 1—) PHONE (2): �����,������ FACSIMILE: g?_2- 6 -7S <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> ❑CHECK BOX TO EXPEDITE REQUE T-$130 FT(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: ❑ List Map—Description: <br /> FILE ADDRESS <br /> Street# Street Name s City E USE ON 1...� <br /> L "nom.,;; ..-....... <br /> HD <br /> 2. 5I �✓ r� �1 I KTd � �� � , o�v'( �), �`j`tj ❑Unit1 <br /> 3. ZUnit 2 <br /> 4. <br /> ❑Unit 2H <br /> 5. i <br /> ----- ......... <br /> .......... <br /> ...... <br /> ._. <br /> s I]UU,it 3 <br /> 7' "Unit 4 <br /> .......................................................A............ ........... ............8. .(]SITE MITIGATION <br /> 9. <br /> 10• /3//'5(CPp unit 5 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> 9UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY M SOLID WASTE FACILITYNEHICLE,klO <br /> OTHER CLEANUP SITE(NON-LOP) El HOUSING ABATEMENT WASTE TIRE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> HAzARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> TIERED PERMITTED FACILITY ❑POOLISPA LAND USE APPLICATION SITES , <br /> TATTooIBODY PIERCING �COMPLAINTIRESPONSE RECORDS OTHER(PLEASE SPECIFY);;u� °�` _ +Al iC <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM (EXCLUDING HOLIDAYS) <br /> 1. List up to ten addresses in the space above. Select the type(s)of files from the list above by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to(209)464-0138 or mail to the address indicated above. Address <br /> ranges will not be accepted.Applications received after 3:00 pm will be processed the next business day. <br /> 2. For assistance in identifying the nature and content of EHD records,please contact EHD at the number noted above. <br /> 3. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten(10) <br /> days after receipt of application. The files will be held for a maximum of five business days for review. Appointments <br /> should be scheduled accordingly. f f <br /> 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. <br /> Future file reviews by the same applicant may require a$130 deposit prior to review. ***'BOXED AREA-EHD USE ONLY*** <br /> ❑ Records provided by Staff-PPR Complete.Staff Name. <br /> Received Time=Jul, 29. =2015=10:20AM--No. 9221 <br /> 711115 <br />